Download End-of-Life ESMO Protocol Project

Running head: END-OF-LIFE ESMO PROTOCOL PROJECT
End-of-Life ESMO Protocol Project
Jacqueline Degen, Cynthia Snook,
Anita M. Stechschulte, and Allison Tayloe
Wright State University
NUR 7005
April 15, 2013
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END-OF-LIFE ESMO PROTOCOL PROJECT
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Abstract
DECREASING PAIN IN THE ACTIVELY DYING PATIENT THROUGH USE OF AN END-OFLIFE SYMPTOM MANAGEMENT PROTOCOL
Funded by project grants from The American Nurses Foundation and National Institute of Nursing
Research
Purpose: The purpose of this evidence based practice change is to determine if ESMO protocol use in an
acute care setting decreases pain and adds comfort to the palliative care patients’ life during the last one to
two weeks of life expectancy.
Synthesis of Evidence Guiding Change: Although palliative care options are available for patients in
the acute care setting, many nurses caring for the actively dying patient have concerns over symptom
management related to patient’s inability to communicate their needs. Previous studies have shown that
use of clinical pathways, such as ESMO protocols, for the dying patient increased the healthcare teams’
ability to appropriately manage symptoms in various clinical settings, as well as increase comfort to the
patient during this time.
Proposed Change: The proposed change for this EBP project will be implementation of an end-of-life
symptom management protocol that includes a standardized order set, documentation tool, consent, and
non-verbal pain scale for measurement of ESMO protocol effectiveness.
Strategies of Implementation: Strategies for implementation include developing the medical record
changes, holding staff meetings to discuss importance and details of pilot project implementation and
needed change, sharing successes and concerns during and after pilot implementation, and sharing
outcomes following completion of the project.
Stakeholders: The active stakeholders in this project include the nurses, physicians, and healthcare team
members who are working in the acute care setting in which the project is taking place (med-surg floor of
hospital). The passive stakeholders in this project include the hospital wide nursing council, director of
nursing research, and director of nursing education.
Method of Evaluation: The method of evaluation for ESMO protocol use will be data analysis of the
electronic medical record use for protocol screening. Significance of relationships between decreased pain
and increased comfort will be measured by the use of non-verbal pain scale (NVPS) as part of the ESMO
protocol. Previous studies have shown improved patient comfort through ESMO protocol use as
measured by pain and dyspnea management. Press Ganey surveys will also be used to determine costbenefit analysis of project implementation following the conclusion of pilot project.
Significance: The significance of this intervention is to have staff feel more comfortable with the care of
the nonverbal dying patient. This EMSO will help the care team to be able to provide the best care
available and will help the care team address end of life symptoms appropriately in the palliative care
patient. ESMO protocol has proven to provide comfort through dyspnea and pain management in
previous research. Thus, implementing ESMO protocol as a standardized order set will not only increase
comfort to the dying patient, but decrease costs associated with symptom management in the dying
patient related to appropriate pain and dyspnea management.
END-OF-LIFE ESMO PROTOCOL PROJECT
TABLE OF CONTENTS
Abstract ______________________________________________________________ 2
Table of Contents _____________________________________________________ 3-4
EBP Part 1: Statement of the Problem _____________________________________ 5-7
Step 1: Assessing the Need for Change __________________________________ 5-7
Statement of the problem _____________________________________________ 5
PICOT ____________________________________________________________ 5
Planning the practice team ____________________________________________ 6
Key informants and stakeholders _______________________________________ 7
EBP Part 2: Critical Appraisal of the Evidence ____________________________ 8-14
Step 2: Locating the Best Evidence ______________________________________ 9
Supporting Material __________________________________________________ 9
Step 3: Analysis of the Evidence _____________________________________ 11-14
Synthesis ________________________________________________________ 11
Study 1 Walling et al: Barriers _____________________________________ 11
Study 2 Walling et al: Symptom Control _____________________________ 12
Study 3 Walker er al: Medications/Order sets _________________________ 13
Study 4 Cochrane Review: ________________________________________ 13
Schematic Framework _______________________________________________ 14
EBP Part 3: Plan a Pilot Test __________________________________________ 14-22
Step 4: Designing Practice Change ___________________________________ 14-15
Model: Evidence-Based Practice Change Model ___________________________ 14
Specific Aims/Objectives _____________________________________________ 15
Client/Population/Setting _____________________________________________ 15
Intervention: ESMO protocol __________________________________________ 15
Special Considerations _______________________________________________ 15
Step 5: Implementation and Evaluation _______________________________ 16-19
Katherine Kolbacha’s Care Theory _____________________________________ 16
Timeline: Gantt ____________________________________________________ 16
Order Sets/Protocols _________________________________________________ 16
Staff Participation ___________________________________________________ 17
Special Accomodations ______________________________________________ 18
Outcomes and Measurement/ Data Collection ____________________________ 19
Donabedian’s Outcome Framework_____________________________________ 20
Ethical Considerations _______________________________________________ 20
Step 6: Integrating and Maintaining Change ___________________________ 21-22
Dissemination of the Evidence _________________________________________ 22
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END-OF-LIFE ESMO PROTOCOL PROJECT
EBP Part 4: Budget Proposal ____________________________________________ 22
Projection/Justification _______________________________________________ 22
Funding/Grants _____________________________________________________ 22
References/Works Cited _______________________________________________ 23-25
Appendices _________________________________________________________ 26-31
Appendix I: Gantt Chart: Project Timeline _________________________________ 26
Appendix II: Non-Verbal Pain Scale (NVPS) ______________________________ 27
Appendix III: Evidence-Based Practice Change Model _______________________ 28
Appendix IV: Plan for Measuring Success Table ____________________________ 29
Appendix V: ESMO Budget Table _______________________________________ 30
Appendix VI: Poster For Dissemination ___________________________________ 31
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End-of-Life ESMO Protocol Project
EBP Part 1: Statement of Problem
In today’s world of continued medical advancements, physicians, and hospitals are ready to offer
patients numerous choices on treatment options regarding particular diseases and diagnoses throughout
the country. Furthermore, nurses are trained to use these high technological advancements and treatments
to save their patients found in life threatening situations. However, many health care institutions lack
appropriate protocols for patients approaching death and many nurses feel uncomfortable with caring for
a dying patient and addressing his or her needs when a palliative care approach is chosen (White &
Coyne, 2011). Previous studies have shown nurse’s top two deficiencies regarding end of life care for
patients as lack of proficiency in discussing end of life options with patients and families and appropriate
pain control during the dying process (White, Coyne, & Patel, 2001). For example, Carol is a nurse on an
oncology unit caring for a patient with a terminal pancreatic cancer diagnosis. The patient has suffered
multiple strokes and cannot verbalize her needs. The patient often grunts, groans, and grimaces, but has
no other signs of verbalization of needs. The nurse has pain medication orders every hour, but does not
know when or how much to give. The patient’s family anxiously waits at her bedside, and the nurse is
confused regarding what they are feeling as well.
Step 1: Assessing the Need for Change
The nurse knows there is a protocol for end of life symptom management but not one in place at
her healthcare facility. A protocol, such as this is, needed for this patient during the palliative care phase
of life to help guide the nurses’ decision making. In the actively dying adult patient who is non-verbal,
how does the use of end-of-life symptom management orders (ESMO) protocol compared to those not
receiving ESMO affect the person's overall comfort and symptom management during the last one to two
weeks of life expectancy?
Walling, Brown- Saltzman, Barry, Quan, and Wenger’s (2008) state that during aggressive
treatment in an acute care setting “inadequate time is devoted to developing care plans to address end of
life (EOL) symptom management” (p. 858). Without a plan this lack leads to inadequate symptom
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management when EOL symptoms occur. Their further discussion notes that physicians may be
uncomfortable guiding comfort care if there are no guidelines to direct said care and may be complicated
by diverse views regarding opiate use at EOL. Additionally, according to White, Coyne, & Patel (2001)
nurses have verbalized that they are uncomfortable with those who are actively dying. Thus,
implementation of ESMO would address not only the physician’s discomfort in guiding care but also
provide the nurse with suggestions for symptom management, reminders of requirements for
implementation of the ESMO, and specific orders to address symptom management. Topolovec-Vranic,
et al. (2010) state that “in the presence of life-threatening illness pain assessment and management are
often overlooked or underappreciated by the health care team.” (p. 345) One often hears bedside nurses
express he or she is uncomfortable in caring for nonverbal dying patients as they are unsure as to how to
assess effectively and/or manage that discomfort.
The population or individuals this evidence-based project will focus on are those non-verbal
adults in his or her last days of life. According to Hospice (n.d.), there are two phases a person approaches
with impending death: pre-active phase and the active phase of dying. Those individuals in the active
phase of dying are the individuals whom the intervention will be used. Individuals in his or her last few
days of life may still experience discomfort but cannot verbalize that discomfort.
Changing the way nursing interventions are done involves approaching a problem with the best
evidence available (Melnyk, 2011, p. 9). The options for interventions are to continue ‘as usual’ and allow
each nurse to dictate whether the patient is comfortable or not. Another option would be apply a pain
specific assessment tool, such as the ABBEY assessment tool for pain or the Nonverbal Pain Scale
assessment tool. Another intervention could even be relying on family to dictate whether the patient is
comfortable or not. However, according to Walling et al, (2008) designing an overall comfort plan that
involves the entire end of life symptom management, not just pain control, is the best approach to
optimizing overall comfort at the end of life (p. 858). Using the ESMO protocol, end-of-life symptom
management orders helps guide the use of medications, such as opiates, and other palliative modalities (p.
857).
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The intervention chosen is the implementation of an end of life system management protocol
(ESMO). The protocol would allow the staff on the floors not familiar with the care of a dying nonverbal
patient to feel more at ease and to have the assurance that the patient is getting the best care. The use of
the protocol could be used not just with the floor nurses but with other ancillary departments: social
workers, case managers, respiratory therapy, palliative care team, and pastoral care. The ESMO
incorporates not just pain but also other end of life concerns. As it has been written previously the use of
an ESMO can improve the quality of care given to the nonverbal dying patient.
The need for a protocol to help nurses and other care teams’ respond to the dying patient is
necessary to give the best care available. The key to the implementation of this protocol is educating the
staff and other necessary personal. The protocol helps to bring about continuity of care for both the
patient and his or her family. The ESMO will allow the nurse to feel more comfortable with use of pain
medication and other symptoms. Knowing that the patient will have adequate symptom management is
needed at this stage of life. In planning the practice change, nearly every discipline of the health care team
should collaborate. Administration must support and enable implementation of an evidence-based tool.
Pharmacy will be consulted on adequate dosing of medication. The education department will insure all
members of the interdisciplinary team are aware of how and when to implement the tool. Social work and
pastoral care will facilitate agreement by the family for implementation of the ESMO. Respiratory
therapy, physicians, and nurses must be knowledgeable and comfortable using the ESMO effectively.
Looking within the organization to develop a team, two stakeholders help make a project happen:
active stakeholders and passive stakeholders (p. 55). In the case of implementing end-of-life symptom
management orders (ESMO) protocol the active stakeholders would be those people or councils that
would be actively participating in evidence-based intervention: physicians, nurses, patients, family, and
other ancillary staff such as nurse technicians. Passive stakeholders are not directly involved with the
implementation but still play a part in its success. Passive stakeholders are risk management, education
departments, managers, executive officers, the evidence practice council, and the research board. It can be
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difficult to identify all the stakeholders upon the onset of a project, remaining open to others and sharing
the project plan will help with communication, support, and implementation (Fineout-Overholt, 2011).
EBP Part 2: Critical Appraisal of the Evidence
After addressing the active and passive stakeholders for this evidence-based practice project, it is
important to consider agencies outside the hospital setting that may be important. Agencies such as
outpatient hospice facilities, local cancer outreach support groups, and the American Association of
Critical Care Nurses would all be important to include in implementing the ESMO protocol. Attention to
individuals and groups, such as those needed to improve the outcomes or change practice related to the
project implementation (Melnyk & Fineout-Overholt, 2005). Outpatient hospice facilities in the area may
offer insight into end of life care protocols and ease the implementation of such protocols within the
hospital setting (Kehl, Kirchhoff, Kramer, & Hovland-Scafe, 2009). Local cancer outreach support groups
have two purposes. First, it offers information to clientele regarding the protocol being implemented at
the hospital. Secondly, it offers benefits to both patients and families facing palliative care options and
serve as a resource for hospital setting to reach out to families as part of the ESMO protocol. The
American Association of Critical Care Nurses (AACN) has cited palliative and end of life care as one of
three major initiatives in current health policy agendas and evidence-based practice. Thus, including
AACN as an agency would allow potential research funding and supporting evidence based practice
during planning and implementation of the ESMO protocol in the hospital setting (American Association
of Critical Care Nurses, 2013).
The patient care-team will help implement the new intervention into practice and coordination of
all the disciplines needs to occur to ensure the project is a success. The multitude of information and
expertise available within the team will allow for a smoother transition. Change within the organization is
never easy. However, with proper education and the best available evidence, the new protocol will be
well received. Hopefully sparking a spirit of inquiry for other evidence based projects. Assessing and
addressing the needs of dying patients is difficult for nurses in the health care arena. Fulfillment of these
needs can be especially difficult with the unpredictability of a death and the individuality of end of life
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symptom management (Seow et al, 2010). Many studies have focused on the need for new outcomes,
frameworks, and quality indicators associated with end of life symptom management as well as a push for
ESMO (end of life symptom management order) protocols within practice (Walling, Ettner, Barry,
Yamamoto, & Wenger, 2011).
Step 2: Locating the Best Evidence
Previous studies have shown that comfort is achieved through adequate pain and dyspnea
management, which has been improved with the use of ESMO protocols (Walling et al, 2008). Pain and
dyspnea management in the dying patient may be difficult to assess related to the patients’ inability to
express their needs verbally. Pain is often described as suffering through physical or emotional
discomfort, whereas dyspnea is noted as discomfort in breathing patterns (Seow et al, 2010). Both pain
and dyspnea, although subjective, are indicators that affect a patient’s sense of comfort. ESMO protocol
often includes a non-verbal pain scale that addresses indicators of facial movements and airway
management to control patients’ symptoms in the last weeks of life. Therefore, the focus of this EBP
project centers on the use of ESMO protocols to improve comfort in the form of pain and dyspnea
management in the dying patient compared to standard care.
A systematic and thorough review of multiple databases was conducted and included: CINAHL,
PUBMED, Cochrane Review, and Agency for Health Care Research and Quality (AHRQ). Other
supplemental material was reviewed as well: research studies, patient education materials, benchmarks,
and guidelines. The use of ESMO protocols within health care institutions was evaluated and synthesized
for importance of information.
In 2011 Nottingham University Hospital launched benchmarks “to encourage staff (to take)
ownership and involvement in … raising standards in fundamental care” to improve end-of-life care
(Warren, Freer, & Molinari, 2011, p. 15). Nearly half of all deaths occur in the acute care setting (p. 16),
yet hospital-based nurses, especially those in an acute care setting, do not feel comfortable taking care of
or managing symptoms at end-of-life (White & Coyne, 2011). Developing standards of measurement in
end-of life care raises awareness of the best practices available and gives nurses the confidence to care for
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this challenging population. One of the 12 benchmarks set forth by Nottingham University Hospital is for
“nurses to know how to manage common symptoms” such as pain, secretions, and dyspnea in a dying
patient (Warren, Freer, & Molinari, 2011, p. 17). These benchmarks include that staff should have access
to and know how to use end-of-life symptom management pathways to give the patient comfort through
symptom management.
In addition to these guidelines, the Agency for Health Care Research and Quality (AHRQ) has
proposed a framework centered on end-of-life symptom management in the form of pain, dyspnea, and
delirium management (Seow et al, 2010). Although this framework is focused on end-of-life care for
cancer patients, the assessment of quality indicators that ease the suffering and provide comfort have
generalizability toward any dying patient. This framework was developed from multiple research studies
surrounding end-of-life care. The AHRQ framework contains an assessment and diagnosis category for
symptom management within a five-step process. Thus, it is important to note the nurse’s role in
evaluating patient needs and symptoms during the palliative care stage. Additionally, this framework
includes assessment of factors to gauge appropriate ESMO use in the dying patient during the last one to
two weeks of life expectancy (Seow et al, 2010).
Recently, many hospitals have begun to develop inpatient hospice units and palliative care teams
to address the needs of patients in the last weeks of life expectancy (Caple, 2012). Palliative care teams
focus have evolved based on the World Health Organization’s definition to include management of
patient and families’ physical and psychological needs during the palliative care phase of life. Within
recent years, progress has been made to include development and use of the end-of-life-symptom
management within institutions. As part of that development, palliative care teams have been formed to
provide comfort to the dying patient (Caple, 2012). Thus, the development and support of such studies
and government research agency guidelines is important to address the current findings and to advocate
for ESMO protocol use. Health care facilities need to make it a priority to maintain comfort through
adequate pain and dyspnea management during a patient’s last one to two weeks of life expectancy.
Step 3: Analysis of the Evidence
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The research was evaluated regarding ESMO protocol use compared to standard care in
comforting the dying patient in the last one to two weeks of life expectancy and there is ample evidence
supporting the general use of ESMO protocols within institutions (Walling et al, 2011). However,
whether ESMO protocol improves specific outcomes has not been rigorously studied (Chan & Webster,
2010, 4). Designing such studies is a challenge with the dying population because of potential ethical
issues in conducting controlled studies (p. 9). Although further rigorous research needs to be conducted,
end-of-life care pathways have been shown to be effective in managing certain conditions (p. 9).
In health care facilities where ESMO protocols are available studies have shown that clinicians
use these protocols approximately 50% of the time even though the use has been proven to increase
patient’s comfort (Walling et al, 2011). These finding strengthen the argument that a change is needed in
providing comfort through ESMO protocol use. Such findings support the use of ESMO protocol as the
‘gold standard’ and indicate a need for change regarding ESMO protocol use within health care
institutions to improve comfort in the dying patient in the last one to two weeks of life.
In a study conducted by a research team within a university-center hospital, data and calculations
were gathered on dying patients within the facility to assess use and non-use of the ESMO protocol
(Walling et al, 2011). Analysis of this study’s results concluded that use of the ESMO protocol helped
increase patient comfort in the dying patient. It also concluded that non-use of the ESMO protocol by
physicians and nurses was because of inadequate attention to patient comfort during a time of expected
death (Walling et al, 2011). Barriers exist with the use of ESMO protocol use within this specific
population of dying patients. Such barriers can be types of insurance and diagnoses on admission to the
hospital. This study was both statistically and clinically significant. The confidence interval for this study
was measured at 95%, leaving little room for random error. The confidence interval for this study was
used to evaluate barriers to ESMO use in the inpatient dying population, which was said to be increased
in younger, underinsured, and minority populations (Walling et al, 2011). This study is clinically
significant because the results are reliable and valid. The study addressed barriers to ESMO protocol use
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within healthcare institutions to increase comfort for dying patients in their last one to two weeks of life
expectancy.
The PubMed database search using the keywords “end-of-life symptom management” and
“comfort-care end-of-life symptom management” revealed four studies with two relevant to the PICOT
question. Of the two relevant studies, one was a repeat of a study already included in this appraisal. The
chosen study by Walling et al. (2008), Assessment of Implementation of an Order Protocol for End-Life
Symptom Management, evaluated the implementation of an inpatient end-of-life symptom management
protocol (ESMO). This study’s results are valid because this is a Level IV study with implementation of
the chosen intervention, ESMO (Appendix 1). Over the course of 342 days, 127 in-patients in the final
day(s) of life were given the chosen intervention. The ESMO protocol was to be initiated by physicians
and nurses and evaluated if such a protocol was useful in caring for a dying hospitalized patient. The
study was a controlled study that measured pre and post knowledge and attitudes toward ESMO.
Although these outcomes were not relevant to the PICOT question the EBP research team wanted to
measure, the measurements of pain and dyspnea symptoms were subsequently included in the study and
these were relevant to the PICOT question (p. 860).
The results are reliable because the level of significance was placed at p<0.01 (Walling, BrownSaltzman, Barry, Quan, & Wenger, 2008, p. 859) (Appendix 1). The physician and nurse responses were
compared using 𝑥 2 tests (p. 859). This indicates a probability ratio, 1 out of 100 chances that the result
was an accident or there was a 1% chance the result was obtained by accident. These results would be
considered significant, meaning that the researchers are 99% sure the study variables do have a
relationship (Heavey, 2011). However, the study also measured specific symptom control (comfort) such
as pain and dyspnea so this study was chosen to be a ‘keeper’. Each symptom was measured on how well
the physician or nurse perceived the symptom to be managed. The results will help in caring for patients
because in a majority of cases the clinicians believed patients had adequate symptom control in 82%
(physicians) versus 77% (nurses) (Walling et al., 2008, p. 862). Although the authors of the study
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concluded that a standardized protocol may not fully be sufficient in managing all symptoms, a set
protocol “is a step toward improving care for dying hospitalized patient” (p. 857).
Walker, Nachreiner, Patel, Mayo, and Kerney (2011) retrospectively compared patients over a
six-month time-period and grouped the patients into three groups. The first group was those with standard
care who had no comfort or palliative care orders on the chart. The second was those who had comfort
measure only orders written at the doctor’s discretion. The third was those with a palliative care order set
implemented as ESMO. Their discussions of findings note that in the group with the ESMO, availability
of all types of palliative medications (opioids, anxiolytics, anti-secretory agents, etc.) was significantly
higher. The authors also note they were encouraged by the frequency of use in ESMO orders relatively
soon after implementation of the EMSO protocol even though they were in a smaller community teaching
hospital where staffing and time for palliative care education is often more limited than in larger hospitals
(p. 285). The authors further noted their findings do support previous reports of successful ESMO
implementation at large hospitals (p. 285).
The Cochrane review synthesized multiple studies regarding the use of end-of-life pathways
versus the non-use of critical pathways to improve the care given to the dying patient. Various databases
like MEDLINE and EBASE were used. The criterion for inclusion was the use of end-of-life pathways
versus non-use. It was noted that the pathways were patient-centered and kept the focus on the comfort
needs of the dying patient. The pathways help to lead the health professional to give the best care in the
best amount of time (Chan R, 2010). It can be noted that the Cochrane systematic review is the highest
level of evidence, has homogeneity, and it is the least biased of all the evidence available. Of the 920
studies pulled for review, none of the studies were found to have met the criteria needed for rigorous of a
systematic review. The pathways according to this review of evidence noted that results from pathways in
some disease processes were beneficial and in others it did prove to provide the needed evidence to
encourage the use of the pathways. The review states that even though the pathways were not proven to
support the criteria the pathways are helpful for managing certain issues just not all of them (Chan R,
2010).
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The scheme used to determine the strength of the evidence to make a practice change was based
on the quality, the quantity, and the consistency of the evidence (Melnyk & Fineout-Overholt, 2011, p.
76). The evidence found was a moderate level of evidence, mostly nonrandomized retrospective studies
and case studies. There was a large quantity of studies supporting ESMO in general. The quantity of the
evidence regarding specific outcomes is low as well, with very few making reference to ‘comfort’. The
consistency of the evidence has shown that end-of-life care pathways helped clinicians caring for those in
the active stages of dying. The consistent findings noted in the literature of effective implementation lead
to positive patient outcomes providing reliable support for implementation of ESMO and are summarized
in the synthesis table as noted in Appendix I. Chan says “until there is evidence indicating harms caused
by the end-of-life care pathways, the use of (such) pathways may be continued” (Chan & Webster, 2010,
p. 7). The recommendation from this EBP team will be to implement an end-of-life protocol with the
potential to help increase comfort in the actively dying person.
EBP Part 3: Plan a Pilot Test
The model that this group has chosen is the Model for Evidence- Based Practice Change
developed by Rosswurm and Larrabee. This model looks at quality indicators outside the organization
and links the indicators to interventions (Gawlinski, 2008). It is with this model that will best help
implement the new change protocol to the organization. The concepts are clear and easy to understand.
The chart that organizes the steps, Appendix III, is straightforward and can be followed quickly. This
model takes the nurse from the beginning of the process, with assessing the need for change,
implementing, and maintaining the change into the organization. One of the most important reasons that
this model works well is that it can be used on a variety of patients, projects, departments and programs
(Gawlinski, 2008). The first three steps have already been executed, the team can complete steps four
through six.
Step 4: Designing Practice Change
The specific aim for this evidence-based project is to look at our PICOT question. How does the
use of end-of –life symptom management orders (ESMO) protocol compared to those not receiving
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ESMO affect the person’s comfort and symptom management during the last one to two weeks of life
expectancy? It is from this question that we aim to implement an end of life protocol that will help
inpatient staff better to understand how to care for the nonverbal dying patient. It is also the aim of this
practice change to include multiple disciplines of the organization to incorporate a smooth transition of
the protocol.
The clinical setting for the implementation of the protocol will be a medical surgical floor in the
hospital. The 25-bed unit will be ideal the setting because the nurse patient ratio is low and this will make
it easier to implement the new ESMO. The patient population will be those nonverbal persons toward the
end of life. The protocol will be implemented when the physician has initiated palliative care consult
although the patient can be located on any of the various floors in the hospital. Nurses on the floor where
the patient is located will approach the family and explain the purpose of the study. Consent will be
reviewed and signed. The number of patients involved will be limited due to the nature of the patient that
is needed for the use of the protocol. Attrition could possibly be a problem.
The support needed for the project change from all the nurses, physicians, and administrators as
long as the proper amount of education has been done. The project group will need to make sure that the
staff that will implement the pilot has a good understanding of all components of the protocol. Lack of
communication of a project change will be the first thing that will slow the implementation process.
The ESMO protocol will be measured through use of a nonverbal pain scale that will assess both
pain and dyspnea in the dying patient during the last one to two weeks of life. ESMO protocol, in this
EBP project, functions as a specific order set that will be available via the hospital information system for
use by the physicians working within the unit. The purpose of the ESMO protocol is to manage symptoms
in the palliative care patients during the last one to two weeks of life expectancy (Walling et al, 2008). All
patients within the unit in which the intervention is taking place will be screened for appropriateness of
ESMO protocol use.
Step 5: Implementation and Evaluation
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Katherine Kolcaba’s theory of comfort appropriately explains the use of ESMO protocol in the
dying patient during the last one to two weeks of life expectancy. In Kolcaba’s (1991) theory, a patient
has needs that when addressed through comforting interventions provided by the nurse leads to enhanced
patient comfort (Kolcaba & Kolcaba, 1991). In this scenario, the patient’s needs are both physical and
emotional suffering that the patient is unable to express verbally, which is managed through ESMO
protocol use as the intervention and leads to enhanced comfort, measured by pain and dyspnea
management.
During implementation, an intervention group of eligible dying patients in the last one to two
weeks of life expectancy will receive the new ESMO protocol versus a control group who will not receive
a specific protocol in the last one to two weeks of life expectancy. It is important to note that because the
education for this EBP project will include an online education module, the EBP project will be able to be
reproduced (Melynk & Fineout-Overholt, 2011). Time to conduct the study, potential funding sources,
and potential subject base are all important factors to consider when considering the feasibility of this
EBP change (Melynk & Fineout-Overholt, 2011). For use of the ESMO protocol, educational costs for
the physicians and nurses within the unit of change have been evaluated and cost-benefit analysis of EBP
change has been presented to the IRB and research committee of the hospital. The EBP team has been
established and leadership roles addressed to ensure appropriate amount of time to be lead the change
implementation.
Because change often disrupts the balance of an environment, change is often unwelcome and
resisted by those involved (Stonehouse, 2012). People resistant to the change regarding this EBP project
may include both nurses and physicians on the unit in which the EBP project will be implemented. This
resistance may be related to lack of understanding and challenges faced by implementing as new protocol
within the unit. Resistance to change may also be because it requires acknowledgement that current
practice is not providing the highest quality care to patients (Stonehouse, 2012). Implementing a new
protocol will require education for all members of the health care team, as well as rigorous push for
physicians to appropriately screen and order the ESMO protocol for eligible patients. Following this,
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nurses working on the unit will also need to understand the protocol and the appropriate use of the order
sets. The reason for the orders would be to increase comfort to the patient’s during the last one to two
weeks of life expectancy. It is easy for the hospital to weigh the cost-benefit analysis of implementing
such a protocol; however, nurses and physicians may not be able to see the big picture and will need extra
education regarding why this change is necessary (Stonehouse, 2012).
As noted in the Gantt Appendix I, the first step in EBP implementation for timeline will be to hire
and train the EBP team that will consist of physician, clinical nurse specialist, nurses, respiratory
therapists, and a nurse researcher. Roles and leadership positions within the EBO team will need to be
assigned (Melynk & Fineout-Overholt, 2011). Distribution of the literature review will need to be
completed. The ESMO protocol (order set) will need to be added to the health information computer
system at the facility indicating when the practice change will occur. Training of personnel using the
ESMO protocol will occur and a small pilot study of the intervention will be implemented to trial the
change. This pilot study will conclude after one month, during which appropriate changes will be made
for the implementation unit wide of the ESMO protocol in June 2013. Six months of data collection will
accompany intervention implementation and following this time. Data analysis and evaluation of results
will be finalized. Finally, a final report will be submitted to help disseminate the information.
In order to implement the change, the health information system used by the hospital will need to
be updated with the appropriate and agreed upon ESMO order set. This will require not only a cost
benefit analysis, but a return on investment quote. Special accommodations related to computer system
changes will need to be evaluated in order for not only the unit in question, but the entire hospital should
this practice change go hospital wide. In addition to this, nurses, physicians and social workers who work
in the unit in which the change will be taking place will need to complete online educational modules
regarding the purpose and use of the change in order to be competent and comfortable with the change.
Following staff education and prior to pilot implementation, staff needs time to be able to ask questions
about the ESMO protocol and how why the change is needed. Once staff understands the need for ESMO
END-OF-LIFE ESMO PROTOCOL PROJECT
18
protocol use, physicians and nurses will be able to implement the change more effectively (Stonehouse,
2012).
Lastly, special accommodations may need to be made for the patients who will be affected by the
ESMO project change. Patients have the right to be aware of such change and options at the end of life,
which needs to be considered when implementing a project that is said to promote comfort in the last one
to two weeks of life expectancy. This would mean explaining the use of the ESMO protocol to the
patients and families who are affected by using this EBP change project.
There are many strategies that will help increase the support for the project change within this
intensive care unit. It is important to note that engaging stakeholders is key to a successful
implementation of an EBP project (Ford, Fineout-Overholt, Melnyk, & Stillwell, 2011). Thus, prior to our
project implementation, meetings will be held with the triforce hospital wide council who drives research
and EBP projects throughout nursing units, the director of nursing education, who would be considered
passive stakeholders. The ESMO protocol, needs for use, and timetable for change will all be discussed in
these meetings. This will allow for a trusting environment to be built between the EBP change team and
for key stakeholders. Meeting with active stakeholders such as the nurses, physicians, and managers on
the unit participating in the EBP change project will foster collaboration in decision making which is an
important step in getting stakeholders to buy-in (Ford et al, 2011). In addition to this, evidence from the
literature review will be shared during staff meetings within the unit of change regarding increased
comfort associated with ESMO use. There will be a question and answer poster hung on the unit in the
staff breakroom that the EBP change team can respond to in order to elicit more support for the EBP
change project (Ford et al, 2011 ). Finally, a kick-off meeting will be held between the stakeholders
mentioned above and the EBP change team. This meeting will allow stakeholders the opportunity for the
EBP team to ask for input on the EBP change product and finalize the project timeline. This will also
allow for physicians and nurses on the unit to see how many people are supportive of this change, which
will make them less resistive to the implementation.
END-OF-LIFE ESMO PROTOCOL PROJECT
19
Outcomes will be measured using the Nonverbal Pain Scale (NVPS) as illustrated in the
Appendix II. The ratings of five elements, facial expression, activity, guarding, vital sign changes, and
physiologic indicators, will be measured on a scale of zero to ten (with zero described as no pain and ten
described as the highest level of pain possible). This scale was originally developed by Odhner, Wegman,
Freeland, Steinmetz, and Ingersoll (2003) and has been adapted for adult patients from the FLACC scale
(Merkel, Voepel-Lewis, Shayevitz, & Malviya, 1997). Ratings within the study found internal
consistency and reliability through examining: Face, Legs, Activity, Cry, Consolability. The (FLACC)
pain assessment tool and the NVPS are similar and rely on “reasonable evidence of criterion-related
validity; with the FLACC serving as gold standard for nonverbal pain assessment” (p. 264). Wegman
(2005) later revised the scale for use with ventilated patients and Kabes, Graves, and Norris (2009)
conducted a study comparing the validity and reliability of the original and revised versions. They noted
both versions supported overall construct validity and that reliability was acceptable for scores during and
following painful interventions.
In the proposed pilot study of the practice change, retrospective data withdrawal of electronically
documented pain measurement scores for up to two weeks prior to the patient’s death as rated on the
NVPS for patients who died in the hospital over the six months prior to implementation of the pilot
ESMO protocol will be electronically compiled by the information technology department (IT).
Collection will also include patient demographic information, length of stay, diagnosis, and date of death.
Following development and education regarding the pilot ESMO protocol, the subsequent two-week
adjustment period will provide comfort and aptitude in the use of the protocol. The following six months’
of data will be collected in the same manner and compared to pre-implementation data. Comparisons will
be examined by the authors, all registered nurses, of the proposed change. The frequency of the
preliminary data will be collected at one-month, three-months, and following completion of the six-month
period. If at any time it appears the protocol may be having an adverse or harmful effect on patient pain
measurements the study will be forfeited. If the study process and outcomes are favorable,
implementation of the practice change will move forward.
END-OF-LIFE ESMO PROTOCOL PROJECT
20
Donabedian’s (1987) outcomes framework emphasizes structure, process, and outcomes.
Mitchell, Ferketich, & Jennings (1998) describe structure as “having the right things,” processes as
“doing the right things,” and outcomes as “having the right things happen” (p. 43). Use of this framework
will work well with implementation model being used, the Model for Evidence-based Change, as the
model moves through the beginning of the process with assessing the need for change to implementing
and maintaining the change into the organization that includes the process and outcome framework
elements. The result of the process (doing the right thing = ESMO protocol implementation) will be easily
seen in the outcome (having the right things happen = decreased patient pain as rated by the NVPS) as
compared to pre-implementation of the ESMO protocol.
The collection of data requires the evidence-based team to ensure protection of rights and respect
for those subjects involved in the pilot study (Pollitt & Beck, p. 709). Death can be a difficult and
emotional time and obtaining consent for the intervention, such as ESMO will need to be handled with
care. Consenting to end-of-life protocol might seem like the logical thing to do; however a recent study by
Walling et al., “Missed opportunities: Use of an end-of-life symptom management order protocol among
inpatients dying expected deaths” found that those patients who had no insurance and minorities tended to
refuse such an intervention. It was believed that there was a “lack of trust and an unwillingness to agree to
anything less than full aggressive treatment” (p. 411). Taking these patient preferences into
consideration, a plan that helps the team leader and a spiritual counselor consult with family could help
with obtaining consent.
Implementing change is never easy, but with persistence, patience, and perseverance change can
happen (Melnyk & Fineout-Overholt, 2011). The plan begins with administration leaders and
stakeholders having been informed of the vision. Next, the internal review board would need to ‘clear’ the
project to ensure human subject respect and rights. The EBP team will begin by touching the hearts of
nurses through a video and exemplar experience of a person not receiving ESMO compared to someone
who had received the protocol. Building excitement and an emotional experience will help igniting the
spirit of inquiry among staff. Beginning the project on a small step, involves finding those who are
END-OF-LIFE ESMO PROTOCOL PROJECT
21
‘champions of change’. A kick off meeting that shares the structured protocol, orders, documentation tool,
and procedures will give these staff members the needed tools to implement the project. A mid-project
meeting will be held to monitor change progress. Those staff members involved will be able to share
successes and failures. Most of all, the EBP team will encourage staff and offer incentives when outcomes
have been successfully met. Celebrating successes will give motivation and keep the ‘fire’ alive when
things become difficult.
Step 6: Maintaining Change
Once the pilot project has been completed, the next step is devising a plan to monitor the longterm effects of the practice change. Listening to feedback from staff members through success sharing
discussions, ESMO documentation tools, and with data collected will determine the success or failure of
this EBP pilot project. Several sources of data will be analyzed such as the electronic medical record
(EMR), NVPS, ESMO documentation tools, staff communication, and family communication. These
sources of data will be analyzed to evaluate whether the project should be adapted, adopted or rejected
(Melnyk & Fineout-Overholt, 2011, p. 257). Collection of post-pilot project data will be compared and
analyzed to the standard care date prior to implementation. This analysis will provide conclusions and
measurable outcomes that administrative leaders and key stakeholders will find valuable in determining
the sustainability of this project. The anticipated outcomes (Appendix IV) along with other outcomes
should be considered. Other outcomes (Appendix IV) to consider are the quality of care improvements,
efficiency of processes, environmental changes, and timeliness of project events also need to be
considered.
Communicating change project outcomes with key stakeholders is the first step in maintaining the
EBP project change. The EBP team will determine success or failure based on whether the outcomes were
achieved, if staff properly used protocol, and if costs stayed within budget. This information will be
presented to those stakeholders through a post-project poster presentation along with scorecards (Melnyk
& Fineout-Overholt, 2011, p. 234). The presentation and scorecard will reinforce operational
performance, quality performances, and staff/family satisfaction score. Continuing communication with
END-OF-LIFE ESMO PROTOCOL PROJECT
22
administration, stakeholders, and staff is crucial in implementing the integration of the project change into
standard practice. The implications of this EBP project will ensure that those persons in the active stage of
dying will receive evidence-based care that improves comfort. Clinical circumstances, patient
preferences, research evidence, and health care resources available were considered when developing this
EBP project. Disseminating the information outside the organization at professional conferences or in
nursing publications will help other nurses to develop and evidence-based practice.
EBP Part 4: Budget Proposal
The end of life system management (ESMO) pilot project will be funded by the use of project
grants. The American Nurses Foundation Nursing Research grant program provides funds for beginners
and experienced nurse researchers to conduct studies that contribute toward the advancement of nursing
science and patient care. Our project, if additional money is needed, also can be funded with the help
from the NIH through the National Institute of Nursing Research. The budget (Appendix V) will consist
of new materials to help with implementation and education. The protocols, order sets, and computerbased training are a one-time fee and would not require further funding. This would decrease the cost of
sustaining the project. Incentives will be offered to those staff members who have shown successes and
are a ‘champion’ for this evidence-based practice change. All staff completing the pre and post
implementation survey offered through Survey Monkey will receive a T-shirt for participation.
The overall cost of the evidence-based practice change is $7,066.75 with the majority of cost
being attributable to the time personnel will need to spend in obtaining consents for the pilot, in family
counseling, and in data collection. Yet once implemented, the savings in terms of human suffering for the
nonverbal patient are incalculable. As noted earlier, end-of-life care pathways have been found to lead to
positive patient outcomes and will also help clinicians in caring for the dying. Melnyk and FineoutOverholt (2011) note evidence-based practice is essential in delivering quality healthcare and outcomes
(p. 3). Additionally, there is no cost associated with continuation of the practice change once
implemented.
END-OF-LIFE ESMO PROTOCOL PROJECT
23
References
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Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A
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Merkel, S,, Voepel-Lewis, T., Shayevitz, J., & Malviya, S. (1997) The flacc: A behavioral scale for
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APPENDIX I
Project Timeline
April
Implementation
Hire and train EBP team.
Obtain IRB approval for
EBP project
Literature Distribution
Add ESMO order set to
HIS
Train physicians and
nurses on ESMO
protocol
Pilot Implementation in
Unit
May
June
July
Aug
Sept
Oct
Nov
1st
15th
30th
5th
15th
15th
Implementation/Delivery
of Intervention
15th
15th
Collect Data and
Measure Outcomes
15th
15th
Analyze Data/Evaluation
Submit Final Report
Dec
15th
15th
END-OF-LIFE ESMO PROTOCOL PROJECT
Appendix II
Non-Verbal Pain Scale (NVPS)
27
END-OF-LIFE ESMO PROTOCOL PROJECT
APPENDIX III
Steps in Model for Evidence-Based Practice Change
Melnyck and Overholt p. 255
28
END-OF-LIFE ESMO PROTOCOL PROJECT
29
APPENDIX IV
Plan for Measuring ESMO Success
Outcome
ADP
Mortality Rates:
HWMR and unit specific MR
Plan for Measuring ESMO Success
Measurement
> # of expired persons on unit
>Death rates hospital wide



Source/Owner
EMR
EMR
Discuss at meeting


EMR
manager tracking






NVPS
EMR
Staff
Staff
EMR
Documentation Tool


Documentation Tool
EMR



EMR
Staff
Documentation tool




Billing Data
EMR
IT
Documentation Tool


Press Ganey scores
Documentation Tool
>per unit
ESMO
Comfort:
*Pain
*Dyspnea
Quality Care
>intervention unit
>Number of persons receiving
>Number of persons refusing
>Scale scores with SC
>Scale scores with ESMO
>Family
communication/response
Efficiency of Processes
>Time of initiation
>Time from initiation to death
Environmental change
>Order set use
>Use of order sets
>Use of mentors
>Comfort care supplies
>Staff response
ROI in ESMO
1. Cost of ESMO
*Personnel
*Supplies
*IT changes
>Personnel time ESMO/SC
>Average LOS
>Cost of supplies
>Cost of IT
2. Improved PSS
>PSS hospital wide
>SC
>ESMO
ADP=actively dying person
HWMR=hospital wide mortality rate MR=mortality rate
EMR=electronic medical record
ESMO=end-of-life order protocol NVPS=non-verbal pain scale ROI=return on investment SC=standard care
IT=information technology department LOS=length of stay PSS=patient satisfaction scores
END-OF-LIFE ESMO PROTOCOL PROJECT
APPENDIX V
ESMO Budget Plan
30
END-OF-LIFE ESMO PROTOCOL PROJECT
APPENDIX VI
Poster for Dissemination
31